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Phase 2 GI and Surgery > 1. IBD, GI bleeding and Malnutrition > Flashcards

1. IBD, GI bleeding and Malnutrition Flashcards

1
Q

What are haemorrhoids?

A

abnormal swelling/enlargement of the anal vascular cushions

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2
Q

Describe the following classification of haemorrhoids:

  1. first degree
  2. second degree
  3. third degree
  4. fourth degree
A
  1. remain in the rectum
  2. prolapse through the anus on defecation but spontaneously prolapse
  3. prolapse through the anus on defecation and need digital reduction
  4. remain persistently prolapsed
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3
Q

Name 3 risk factors for haemorrhoids

A
  • excessive straining to defaecate
  • increasing age
  • raised intra-abdominal pressure (pregnancy, chronic cough, ascites)
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4
Q

What is the main presenting feature of haemorrhoids?

A

painless, bright red rectal bleeding

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5
Q

what investigation is used to diagnose haemorrhoids?

A

proctopscopy

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6
Q
  1. How are haemorrhoids generally managed?
  2. When is rubber band ligation indicated?
  3. When is surgical intervention indicated?
A
  1. conservatively - increased fibre and fluid; laxatives; topical analgesia
  2. symptomatic first and second degree haemorrhoids
  3. symptomatic third and 4th degree haemorrhoids
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7
Q
  1. What are anal fissures?

2. With what other condition are anal fissures common?

A
  1. tear in the mucosal lining of the anal canal, distal to the dentate line
  2. IBD (in which perianal abscesses and anal fistulae can complicate the fissure)
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8
Q
  1. How does a patient with an anal fissure present? (3)

2. Name 4 risk factors for the development of an anal fissure

A
    • intense pain post defaecation
    • bleeding
    • itching
    • constipation
    • dehydration
    • IBD
    • chronic diarrhoea
      * all are associated with inflammation/trauma to the anal canal
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9
Q
  1. What is an anorectal abscess?
  2. What are they thought to be caused by?
  3. How are anorectal abscesses classified?
A
  1. collection of pus in the anal or rectal region
  2. blockage of the anal ducts, which are usually involved in mucus secretion to aid the passage of faecal matter through the anus
  3. based on location (perianal, ischiorectal, intersphincteric, supralevator)
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10
Q

How will a patient with an anorectal abscess present?

A
  • perianal pain; worse on sitting down
  • localised swelling/itching/discharge
  • systemic symptoms (if severe)
  • erythematous, fluctuant, tender perianal mass
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11
Q

What is a fistula in ano?

A

abnormal connection between the anal canal and perianal skin

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12
Q

Name 5 risk factors for fistula in ano

A
  • anorectal abscess (majority of cases)
  • IBD
  • systemic disease - TB, HIV
  • Hx of anal trauma
  • previous anal radiotherapy
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13
Q

How may a patient with a fistula in ano present?

A
  • recurrent perianal abscesses

- Intermittent or continuous discharge onto the perineum, including mucus, blood, pus or faeces

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14
Q
  1. What is the main investigation for fistula in ano?
  2. What system is used to classify fistula in ano and how does it do so?
  3. How are anal fistula’s managed?
A
  1. proctoscopy
  2. PARK’S CLASSIFICATION
    - intersphincteric
    - trans-sphincteric
    - suprasphincteric
    - extrasphincteric
  3. Asymptomatic fistulae managed cinservativelt
    fistulotomy
    seton through fistula prevents abscess formation
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15
Q

Where is the gut microbiome normally found?

A

terminal ileum and colon

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16
Q
  1. Which part of the gut is usually almost sterile?

2. Name 5 mechanisms which promote this sterility

A
  1. proximal small intestine (duodenum and jejunum)
    • peristalsis
    • gastric acid and enzymes
    • bile salts
    • pancreatic enzymes
    • mucosal IgA and macrophages
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17
Q
  1. What is bacterial overgrowth syndrome?
  2. How does it normally occur?
  3. How does it disrupt normal physiology?
  4. How does it present?
  5. what test confirms diagnosis of bacterial overgrowth?
A
  1. presence of bacteria within the normally sterile proximal small intestine
  2. malfunction of homeostatic mechanisms or anatomical abnormalities
  3. presence of bacteria interferes with the absorbative capacity of the small intestine, and may also induce mucosal inflammation
  4. diarrhoea, steatorrhoea
  5. hydrogen breath test
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18
Q

Define the following:

  1. Marasmus

2. Kwashiorkor

A
  1. lack of protein and calories

2. lack of protein

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19
Q

Name 3 types of in patients that usually require nutritional support

A
  1. all severely malnourished patients
  2. moderately malnourished patients who are not expected to eat for >5 days
  3. normally nourished patients expected not to eat for >5 days or expected to eat less than half their normal intake for >8-10 days
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20
Q

What type of nutritional support is preffered

A

Enteral (uses GI tract)

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21
Q
  1. What is re-feeding syndrome?

2. What electrolyte imbalances can occur in refeeding syndrome and why?

A
  1. syndrome of metabolic disturbances that occur as a result of reinstituion of nutrition in a patient who has been starved/severely malnourished
  2. hypophosphataemia, hypokalaemia, hypomagnesemia
    during starvation, insulin secretion is decreased; upon refeeding, insulin is secreted - this promotes cellular uptake of phosphate, potassium and magnesium.
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22
Q

Name 4 examples of enteral nutrition

A
  1. oral - supplimentation
  2. NG tube
  3. percutaneous endoscopoc gastrostomy (PEG)
  4. needle catheter jejunostomy
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23
Q
  1. What is parenteral nutrition?

2. What is a serious complication of parenteral nutrition

A
  1. IV infusion of nutrients via a central or peripheral line
    should only be used if enteral feeding is not possible
  2. catheter related sepsis
24
Q
  1. where is the main site of absorption?

2. where are bile acids and vit B12 absorbed?

A
  1. jejunum

2. terminal ileum

25
Q

explain the following clinical presentations of malabsorption:

  1. diarrhoea and steatorrhoea
  2. weight loss
  3. flatulance and abdominal bloating
  4. growth retardation/FTT
  5. oedema
  6. bleeding
  7. muscle cramps
A
  1. unabsorbed nutrients contribute to stool mass. mucosal fluid and electrolyte secretion is increased in diseases associated with mucosal inflammation
  2. impaired absorption of macronutrients
  3. fermentation of unabsorbed carbohydrate
  4. impaired absorption of macronutrients
    5, loss of protein. reduced oncotic pressure
  5. vitamin K and clotting factor deficiency
  6. decreased vit D and Ca absorption
26
Q

Name 3 conditions that can result in bile salt malabsorption

A
  1. bacterial overgrowth
  2. obstructive jaundice
  3. terminal ileal disease/surgery
27
Q
  1. Name the 2 types of anaemia that can occur with IBD
A
  1. iron deficiency anaemia secondary to bleeding from the inflamed bowel (UC) - microcytic hypochromic
  2. B12 deficiency secondary to inflammation of the terminal ileum (Crohn’s) - macrocytic, hyperchromic
28
Q
  1. Which area of the GI tract is affected by coeliac disease?
  2. What type of peptides are damaging factors in coeliac disease?
  3. how is the immunogenicity of these peptides increased?
  4. How is an immune response mounted against these peptides?
A
  1. small bowel
  2. prolamins - e.g. gliadin from wheat
    • resistant to digestion
  3. pass through epithelium and are deaminated by tissue transglutaminase
  4. presented to antigen presenting cells
    production of ANTI-TISSUE TRANSGLUTAMINASE ANTIBODIES
    activation of intraepithelial lumphocytes
29
Q
  1. Describe 4 GI symptoms associated with Coeliac Disease

2. Name some extraintestinal symptoms of coeliac disease

A
  1. diarrhoea and steatorrhoea
    abdominal pain
    bloating
    weight loss/ftt
  2. infertility
    osteomalacia
    neurological symptoms - parasthesia, muscle weakness, polyneuropathy
    dermatitis herpetiformis (puritic lesions over extensor surfaces)
30
Q
  1. Name 2 serological tests which are highly specific for coeliac disease
  2. What investigation is diagnostic?
  3. what are the specific requirements of this investigation?
  4. What other test is required for patients with coeliac disease, relating to an extra-intestinal manifestation?
A
  1. anti-gliadin antibodies; anti-ttg
  2. duodenal biopsy
  3. needs to be performed prior to initiation of gluten free diet
  4. DXA scan (due to risk of osteoporosis)
31
Q

Describe the histology of a coeliac disease biposy (3)

A
  • villous atrophy
  • crypt hyperplasia
  • intraepithelial lymphocytes
32
Q

Name 4 complications associated with coeliac disease

A
  1. osteoporosis
  2. T cell lymphoma
  3. small bowel adenocarcinoma
  4. Oesophageal CA
33
Q

what is the definition of an upper GI bleed

A

blood loss originating proximal to D2/D3

34
Q
  1. What are the 2 cardinal features of acute upper GI bleeds?
  2. what is profound bleeding almost always accompanied by?
A
  1. haematemesis; melaena

2. shock - syncope; feeling faint; hypotensive; tachycardic

35
Q

Name 7 causes of acute upper GI bleeds

A
  1. peptic ulcer disease
  2. gastritis
  3. oesophagitis
  4. duodenitis
  5. varices
  6. Mallory weiss tear
  7. malignancy
36
Q

What investigations are useful for a patient with an acute upper GI bleed? (4)

A
  1. FBC (anaemia)
  2. coagulation profile
  3. LFTs
  4. U&Es
37
Q

Why are urea and creatinine important tests for acute upper GI bleeds?

A

Raised urea in the context of normal creatinine indicates GI bleeding

  • blood products broken down by stomach acid; produces nitorgen
  • nitrogen converted to urea by kidneys
38
Q

Describe the initial management of a patient with an acute upper GI bleed (4)

A
  1. ABCDE assessment
  2. gain IV access (2 cannulas, at least one green or bigger)
  3. group and save
  4. fluid resuscitation
39
Q

What 2 scoring systems are used for acute upper GI bleeds?

  • what do each assess?
  • When are they used?
A

Blachford Score

  • assesses MORBIDITY from GI bleed
  • assesses risk of needing interventions (blood transfusion; endoscopy)

Rockall Score

  • assesses MORTALITY from GI bleed
  • can be done pre- and post-endoscopy
40
Q

Name 4 endoscopic interventions to manage an acute upper GI bleed

A
  1. adrenaline (causes vasoconstriction; never used in isolation)
  2. endoclips
  3. cauterisation
  4. Haemospray
41
Q

What is used in the ongoing management of an acute upper GI bleed?

A
  1. PPI
  2. Stop gastric irritants
  3. Eradicate H pylori (if Clo test is positive)
  4. repeat endoscopy in 4-6 weeks
42
Q
  1. Name 2 causes of massive acute lower GI bleeding

2. what other conditions can cause acute lower GI bleeds? (5)

A
  1. diverticular disease; ischaemic colitis
2. CA
    polyps
    IBD
    haemorrhoids
    anal fissures
43
Q

Which investigations are appropriate for acute lower GI bleeds?

A
  1. proctoscopy
  2. flexi sig/colonoscopy
  3. video capsule endoscopy
  4. angiography
44
Q
  1. How do patients with chronic lower GI bleeding usually present?
  2. What is the cause of chronic lower GI bleeding until proven otherwise?
  3. What investigation is performed to find cause of chronic lower GI bleed?
A
  1. iron deficiency anaemia
  2. cancer
  3. endoscopy (CT can be used as alternative if patient is unfit for bowel prep)
45
Q

Which parts of the GI tract are affected in:

  1. Crohn’s Disease
  2. Ulcerative colitis
A
  1. any part of the GI tract (but has tendency to affect the terminal ileum and ascending colon)
  2. colon only
46
Q

Describe the bimodal distribution of diagnosis of IBD

A

peak incidence at 20-29 and 70-79

47
Q

Describe macroscopic histological changes in:

  1. Crohn’s Disease
  2. Ulcerative Colitis
A
  1. involved bowel usually thickened; cobblestone appearance (fissures and deep ulcers); intra-abdominal fistulae and abscesses
  2. mucosa looks reddened and inflamed; bleeds easily; extensive ulceration; pseudopolyps
48
Q

Describe microscopic histological changes in:

  1. Crohn’s Disease
  2. Ulcerative Colitis
A
  1. inflammation is transmural (all layers of bowel); increase in chronic inflammatory cells; granulomas common
  2. inflammation limited to mucosa; crypt abscesses; goblet cell depletion
49
Q

What are the main presenting features of crohn’s disease?

A
  • diarrhoea, abdominal pain, weight loss
  • constitutional symptoms of inflammation
  • clinical features variable depending on region affected
50
Q

What are the main presenting features of Ulcerative colitis?

A
  • diarrhoea with blood and mucus
  • may have associated lower abdominal discomfort
  • constitutional symptoms not as severe as crohn’s
51
Q

What investigations are useful in the diagnosis of Crohn’s Disease?

A
  • inflammatory markers
  • serology - positive ASCA
  • LFTs (baseline for medn)
  • faecal calprotectin
  • Endoscopy
  • CT
52
Q

What investigations are useful in the diagnosis of Ulcerative Colitis?

A
  • inflammatory markers
  • serology - positive pANCA
  • LFTs (baseline for medn)
  • faecal calprotectin
  • Colonoscopy
  • CT
53
Q

MANAGEMENT OF CROHN’S

  1. What is used to induce remission?
  2. What is used to maintain remission?
  3. What is a problem with use of surgery for Crohn’s disease?
A
  1. glucocorticoids; aminosalicylates (sulfasalazine, mesalazine and mesalamine), anti-TNF (rituzumab)
  2. azathioprine, methotrexate, anti-TNF agents
  3. disease recurrence is high
54
Q

MANAGEMENT OF ULCERATIVE COLITIS

  1. what is the first line treatment for UC?
  2. What is the second line treatment for UC?
  3. What is the third line treatment for UC?
  4. What drug is used to manage an acute severe flare up of UC?
A
  1. aminosalicylates (mesalazine, sulfasalazine)
  2. oral prednisolone
  3. anti-TNF (infliximab)
  4. IV hydrocortisone
55
Q

What are the indications for surgery for UC? (3)

A
  • severe colitis that fails to respond to medical therapy
  • chronic active therapy/refractory disease
  • dysplasia on surveillance colonoscopy
  • those with severe attack in which iv steroids is contraindicated

Phase 2 GI and Surgery (10 decks)

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